Everything your practice should know for more efficient coding and faster reimbursements.
The National Correct Coding Initiative (NCCI) adds another layer of complexity to the already complicated Medicare billing guidelines.
NCCI edits consist of a list of bundled CPT codes that give outpatient rehab therapists information about what codes cannot be billed together during the claims process. Review this comprehensive guide to build your knowledge base when it comes to this aspect of physical therapy, occupational therapy, or speech-language pathology billing.
What are NCCI edits?
NCCI is an initiative of the Centers for Medicare and Medicaid Services (CMS) designed to limit coding errors that lead to incorrect Medicare payments. CMS updates the NCCI Policy Manual for Medicare Services periodically based on current recommendations from the American Medical Association (AMA) and other local and national stakeholders. The policy manual serves as a reference tool during your practice’s Medicare billing practice.
The NCCI edits consist of a table of disallowed code combinations and Medicare contractors are required to process claims utilizing the latest version of the NCCI edits.
The different types of NCCI edits
Outpatient rehab therapists should be aware of the various types of NCCI edits. While most PTs, OTs, and SLPs will encounter PTP edits, you may also come across MUEs and add-on edits in some circumstances.
Procedure to procedure (PTP) edits
PTP edits, delivered as a mutually exclusive CPT code list, prevent therapists from receiving reimbursement for service codes that cannot be used together. PTP edits apply not only within the same discipline but also across disciplines when two therapists bill paired codes under the same provider number.
Each PTP edit consists of two columns, each with one of two codes that comprise the pair. Medicare will pay for the code in column 1 and deny the code in column 2 when they are reported for the same client on the same date.
However, if the code in column 2 is labeled with a “y” (as seen below), then therapists can include the second code if they include modifier 59 with the first code. An “n” means the codes cannot be combined, even with a modifier.
For example:
- Speech-language pathology: 92597 Evaluation of Voice Prosthetic will receive a PTP edit when paired with 36591n; 36592n; 96523n; 97755n
- Occupational therapy: 97542 Wheelchair Management–Assessment and Training will receive a PTP edit when paired with 36591n; 36592n; 96523n; 97164y; 97168y
- Physical therapy: 97750 Physical Performance Test or Measurement will receive an NCCI edit for physical therapy when paired with 36591n; 36592n; 95851n; 95852n; 96523n; 97150n
To avoid PTP edits when using codes that cannot be paired, include an appropriate modifier, when allowed, as described below. PTP codes often have a modifier indicator as follows:
- 0 means the provider can never use a modifier with the code in question.
- 1 means the provider can use an appropriate modifier to distinguish between the services in the code edit pair.
- 9 means the code pair has been deleted and edits no longer apply, eliminating the need for a modifier.
Medically unlikely edits (MUE)
MUEs reject claims that include too many of the same service (or units of a timed service) for the same client on one day. While not every CPT code has an associated MUE limit, an MUE for a CPT code applies when a provider has exceeded the maximum units allowed for the day for a single patient.
Unlike PTP edits, which are available to browse on CMS’s website, many MUE values are confidential and only available for CMS and CMS contractors to use or review. However, CMS does offer a series of resources on their website for providers and billers who have questions about MUEs.
MUEs applies to these types of providers:
- Durable medical equipment (DME) suppliers
- Practitioners and doctors, including PTs, OTs, and SLPs
- Facility outpatient services provided at critical access hospitals
Add-on code edits
This type of edit includes add-on codes with their associated primary codes. Add-on codes receive an edit when they are billed without an appropriate primary code. If a code requires an add-on but is billed by itself, it could result in a denied payment for that service.
CMS has established three subtypes of these codes:
- Type I add-on codes can only be used with certain primary procedure codes for the same practitioner on the same service date.
- Type II add-on codes are not associated with specific procedure codes. CMS allows each claims processor to develop a list of primary procedures for these codes.
- Type III add-on codes are associated with a shortlist of primary codes but could also be associated with primary codes outside that list.
2021 updates to NCCI
The NCCI updates for 2021 did not include any new codes for PT or OT. However, SLPs should know about this newly added list of bundled CPT codes that took effect January 1, 2021:
*Codes appended with “y” can only be billed with the code in the first column when the therapist includes modifier 59. If appended with “n,” the codes cannot be used together, even with a modifier.
New Bundled CPT Codes for Speech-Language Pathologists (as of January 1, 2021)
| Column 1 | Procedure | Column 2* |
|---|---|---|
| 92526 | Treatment of swallowing dysfunction | 69705y; 69706y |
| 92610 | Evaluation of swallowing | 69705y; 69706y |
| 92611 | Modified swallow study | 69705y; 69706y |
| 92612 | Flexible endoscopic eval of swallowing | 69705y; 69706y |
| 92614 | Flexible endoscopic evaluation, laryngeal sensory testing by cine or video recording | 69705y; 69706y |
| 92616 | Flexible endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording | 69705y; 69706y |
CMS also deleted many common NCCI code combinations for PTs and OTs that will no longer result in edits:
Removed Codes for Physical and Occupational Therapists (as of January 1, 2021)
| Column 1 | Procedure | Column 2* |
|---|---|---|
| 97110 | Therapeutic exercises | 97164y; 97168y |
| 97112 | Neuromuscular re-education | 97164y, 97168y |
| 97113 | Aquatic therapy/exercise | 97164y; 97168y; 97110y |
| 97116 | Gait training | 97164y; 97168y |
| 97140 | Manual therapy | 97164y; 97168y; 97750y |
| 97150 | Group therapy | 97164y; 97168y; 97140y; 97750n; 97755n; 97763n; 97110y; 97116y; 97164y; 97168y; 97535y; 97760y; 97761y |
| 97161 | PT eval: low complexity | 97140y |
| 97162 | PT eval: moderate complexity | 97140y, 97161n, 97750n, 97755n, 97763n |
| 97163 | PT eval: high complexity | 97140y, 97161n, 97750n, 97755n, 97763n, 97162n, 97164n |
| 97165 | OT eval: low complexity | 97140y, 97168n, 97750n, 97755n, 97763n |
| 97166 | OT eval: moderate complexity | 97140y, 97165n, 97168n, 97750n, 97755n, 97763n |
| 97167 | OT eval: high complexity | 97140y, 97165n, 97166n, 97168n, 97750n, 97755n, 97763n |
| 97530 | Therapeutic activities | 97113y; 97116y; 97164y; 97168y, 97535y, 97750y |
A note on modifiers and NCCI edits
There are a variety of CPT code modifiers and many strict rules around their use when applied to NCCI edit pairs. Typically, edit pairs should not be billed together, but some modifiers can be used to bypass edits when a service is clinically justified for a single patient during the same visit.
Some of the most common modifier scenarios you may encounter as an outpatient rehab therapist include:
- The 59 modifier indicates that the second billed code in the pair is a “distinct procedural service.” You can use this code to override a PTP edit when applicable (marked with “y” in our charts).
- The X modifiers serve as a subcategory for modifier 59 to provide more billing details.
- XE indicates a separate encounter with the same patient.
- XP indicates that a separate provider delivered the service in question.
- XS indicates performance of the service on a different structure or organ.
- XU indicates an unusual service that does not overlap with the column 1 service.
Frequently asked questions about NCCI edits
Have more questions about NCCI edits and their impact on reimbursements? Here are some of the most common questions we’ve come across, and where you can find more information.
How often do NCCI edits change?
CMS issues PTP and MUE code updates quarterly to reflect changes to evolving healthcare policy and research. The updates are published and available for download on CMS’s website.
Some updates can retroactively be applied to claims that occurred in the prior calendar year. As an example, the most recent NCCI pair deletions for PTs and OTs, released January 1, 2021, can be retroactively applied to any claims happening on or after January 1, 2020.
Are NCCI edits mandatory?
CMS NCCI edits are mandatory when billing Medicare for OT, PT, or SLP services provided in private practice or outpatient hospital settings.
PTP Medicare NCCI edits apply to private practice PTs and rehab therapists as well as to hospital claims submitted through the OPPS for outpatient, rehab, and skilled nursing services. CMS uses the term practitioners to refer to physicians, nonphysician practitioners including private practice therapists, and ambulatory surgical centers. CMS defines hospitals for the purpose of NCCI edits as services provided in outpatient hospital facilities, skilled nursing facilities, outpatient rehab, at the patient’s home, or a private practice.
If you are billing a private insurance company rather than Medicare, check the payer’s policy to determine whether they follow CMS policy for claims. According to the APTA, most commercial insurance companies now include NCCI edits in their automated claims systems.
Which NCCI edits and pairs apply to physical therapists?
According to the American Physical Therapy Association (APTA), most NCCI edits and pairs for physical therapists appear in Chapter XI – Medicine, Evaluation and Management Services. This chapter includes CPT codes 90000-99999.
Which NCCI edits and pairs apply to occupational therapists?
As with physical therapy, occupational therapy CPT codes primarily appear in Chapter XI – Medicine, Evaluation and Management Services. Many OT codes are in the 97000-97999 range.
Which NCCI edits and pairs apply to speech-language pathologists?
SLP codes appear in the same Chapter as OT and PT codes. Common codes for this profession are mostly in the 92000-92999 range.
Where can I find more information about NCCI edits?
CMS and advocacy organizations like the APTA provide a variety of reference materials for outpatient rehab therapist teams and billers. Here are some of the most common resources if you want to take a deeper dive into NCCI edits.
- CMS NCCI edit resources
- CMS fact sheet on correct modifier use
- NCCI edit policy manual archive
- A guide on how to use CMS’s NCCI Tools
- CMS’s NCCI FAQ
- Providers and clinic staff can also contact NCCIPTPMUE@cms.hhs.gov for further assistance.
- NCCI edits and Medicaid | Medicaid.gov
- American Speech Language Hearing Association (ASHA) NCCI practice resources
- American Physical Therapy Association (APTA) NCCI overview for physical therapists
- American Occupational Therapy Association (AOTA) NCCI and billing resources for practices
How does Clinicient’s Insight Platform support NCCI edits?
The Insight Platform is designed to simplify the complexity of compliance with Medicare and other payers. Our system includes a range of features for therapists, billers, and other clinic staff, including:
- Smart alerts for potential edits: Avoid coding errors before you submit the claim, with automatic pop-ups that alert therapists or billers of a potential edit pair.
- Automatic NCCI updates: The Insight Platform will automatically update when new edits are published, so you can continue to provide care without missing a beat.
- Customizable billing rules: Automate your billing process for faster claim creation and submission by creating unique rules for each payer, from Medicare to commercial and private payers.
- A single system, from referral to reporting: Simplify care delivery with a single source of truth for all your documentation, patient records, billing, RCM, and clinic business intelligence needs.
Want to learn more about Clinicient’s Insight Platform? Schedule a free, no-obligations demo to see the whole system in action.
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